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Parent education programmes for children’s behaviour problems

December 1999 West Midlands DES report

PARENT EDUCATION PROGRAMMES FORCHILDREN’S BEHAVIOUR PROBLEMS. MEDIUM

TO LONG TERM EFFECTIVENESS

A West Midlands Development and Evaluation Service Report

Authors: Caroline Dimond & Chris Hyde

Department of Public Health & EpidemiologyUniversity of BirminghamEdgbastonBirminghamB15 2TT

Correspondence to: Caroline DimondDorset Health AuthorityVictoria HousePrinces RoadFerndownDorsetBH22 9JR

ISBN No. 0704421410

Copyright, Development and Evaluation Service Department of Public Health and Epidemiology University of Birmingham 2000.


West Midlands DES report December 1999



Questions addressed by this review:

• What is the evidence that parenting education is effective in the medium to longterm?

• What are the likely costs and benefits from an expansion of service provision inthis area?

Conclusion

In relating the results of this systematic review and cost analysis to the originalproblem of whether health care commissioners should support teaching parentingskills, it is immediately acknowledged that existing research does not provide acomplete answer. However it does provide encouragement to those contemplatingsuch activity provided they stick to the population groups, settings, and interventionswhich have been evaluated. For those sceptical about the value of such activities, it isunlikely that the results of this review will be wholly convincing. In this case thereport identifies where uncertainty exists, namely better estimation of effect sizes,particularly the global impact. The onus in this case is on rigorous research.

Expiry date: 2005



West Midlands Development & Evaluation Service

The West Midlands Development and Evaluation Service (DES) produce rapidsystematic reviews about the effectiveness of healthcare interventions andtechnologies, in response to requests from West Midlands Health Authorities or theHTA programme. Reviews usually take 3-6 months and aim to give a timely andaccurate analysis of the quality, strength and direction of the available evidence,generating an economic analysis (where possible a cost-utility analysis) of theintervention.

About InterTASC

West Midlands DES is a member of InterTASC which is a national collaboration withthree other units who do rapid reviews: the Trent Working Group on AcutePurchasing; the Wessex Institute for Health Research and Development; York Centrefor Reviews and Dissemination. The aim of InterTASC is to share the work onreviewing the effectiveness and cost-effectiveness of health care interventions in orderto avoid unnecessary duplication and improve the peer reviewing and quality controlof reports.

Contribution of Authors

Caroline Dimond undertook the collection and collation of evidence for this review.Chris Hyde gave advice on the formulation of the question and overall process of thereview, helped with some of the writing and structuring of the report and read andcommented on the draft report.

Conflicts of Interest

This work has been undertaken by people funded by the NHS. The authors havereceived no funding from any sponsor in this work.



West Midlands Regional Evaluation Panel Recommendation:

The recommendation for parent education programmes for children’s behaviourproblems – medium to long term effectiveness was:

Supported

For routine use and it was strongly recommend that further evaluation ofcurrent services needs to be carried out.

Anticipated expiry date: 2005

• This report was completed in December 1999

• The searches were completed in January 1999

• The majority of the studies reviewed showed a good result and costs were small.However better research is needed and the programmes need more evaluationbefore making them more available.



1 Introduction............................................................................................................2

2 Background ............................................................................................................2

2.1 Nature of behavioural problems in children ........................................................22.2 Outcomes of behavioural problems .....................................................................22.3 The intervention - importance of parent education..............................................3

3 Problem..................................................................................................................3

3.1 Prevalence/incidence............................................................................................33.2 Current service .....................................................................................................43.3 Proposed service ..................................................................................................43.4 Problem in summary ............................................................................................5

4 Aims of the review.................................................................................................5

4.1 General .................................................................................................................54.2 Specific questions ................................................................................................54.3 Decision tree ........................................................................................................54.4 Conclusions from existing reviews......................................................................7

5 Methods..................................................................................................................7

5.1 Criteria for included studies.................................................................................85.2 Search strategy .....................................................................................................85.3 6.3 Data extraction strategy .................................................................................85.4 Quality assessment strategy .................................................................................85.5 Review analysis ...................................................................................................95.6 Economic analysis ...............................................................................................9

6 Results....................................................................................................................9

6.1 Effects and effectiveness......................................................................................96.1.1 Volume of material ....................................................................................96.1.2 Nature of intervention ..............................................................................106.1.3 Nature of population examined................................................................106.1.4 Nature of outcome measured ...................................................................106.1.5 Study quality and design..........................................................................10

6.2 Effects on child behavioural changes.................................................................106.2.1 Characteristics..........................................................................................106.2.2 Measures of child behavioural change used ............................................116.2.3 Results......................................................................................................11

6.3 Effects on parental well-being. ..........................................................................146.3.1 Characteristics..........................................................................................146.3.2 Measures of parental well-being used......................................................146.3.3 Results......................................................................................................14

6.4 Societal and health service outcomes.................................................................156.4.1 Characteristics..........................................................................................156.4.2 Measures used..........................................................................................156.4.3 Results......................................................................................................15

6.5 Effects in summary and overall effectiveness....................................................176.6 Costs and health economic analysis...................................................................18



6.6.1 Review of the literature............................................................................186.6.2 Estimating programme costs....................................................................196.6.3 Health economics analysis .......................................................................20

6.7 Quantification of cost utility ..............................................................................22

7 Conclusions..........................................................................................................23

8 Appendices...........................................................................................................25

9 References..............................................................................................................3

Tables

Table 1 - Prevalence of behavioural problems in children. ...........................................3Table 2 - Group parent education programmes based in the UK for children at risk of

or with behavioural problems. ...............................................................................4Table 3 - Inclusion and exclusion criteria......................................................................8Table 4 - Summary result table of effect of parent education on child behaviour.......12Table 5 - Summary results table of effect of parent education on parental well-being.

..............................................................................................................................14Table 6 - Summary result table of the effect of parent education on societal and

health service outcomes. ......................................................................................16Table 7 - Overall costs. ................................................................................................19Table 8 - A summary of available information relating to cost savings and potential

benefits of parent education. ................................................................................21

Figures

Figure 1 - Decision tree for the main options and outcomes from parent education.....6


December 1999 West Midlands DES report 1

Summary

• Description of proposed serviceCo-ordinated education on parenting, consisting of 10-15 sessions delivered byexisting staff, using a variety of models.

• EpidemiologyChildren with behavioural problems place a heavy burden on current and futurehealth services. The estimated prevalence of such problems is 10-15% in thoseunder 16 years. This occupies a considerable amount of primary care contact time,and many paediatric community health and child and adolescent clinic referrals, aswell as an unquantified amount of inappropriate use of health services andcasualty departments. Associated parental stress also increases the burden onprimary and secondary health services. Costs to bodies outside the NHS arelikewise high especially in the social services and education sectors. Costs tosociety in terms of later criminality, delinquency and drug use have further beendemonstrated. Behavioural problems in children are linked to poor parentingpractices.

• Number and quality of studies and direction of evidence19 RCTs and pre-post studies addressing medium and long term outcomes (>1year) were identified following an extensive search, which initially identified 4000potentially relevant articles. Despite targeting those study designs with leastsusceptibility to bias, some important general threats to validity were identified,particularly unblinded assessment of outcomes. Results were positive for theeffectiveness of parent education on child behaviour and parental well being andequivocal for the effect on social outcomes.

• Summary of benefits It was impossible to summarise the general benefit identified.

• Cost The likely cost of the service was on average of £353 per client per course with a

Range of £154 to £1121.

• Costs/QALYA cost consequences analysis noted the low cost and low disbenefits of parenteducation and the potentially large benefits and cost savings. Thus, although cost-utility could not be precisely calculated, it seems likely that the cost per QALY ofparent education falls below the £20,000 cost/QALY threshold.



1 Introduction

The importance of parent education is being increasingly highlighted by thegovernment through initiatives such as “Family Support”, “Surestart” and “OnTrack”. Health visitors have been identified as key service providers in this contextand health authorities are being asked to become involved in multi-agency strategiesto deliver packages of care to support parents. Before they commit resources, healthauthorities need information on the effectiveness of such services and some idea ofthe likely balance of costs and benefits.

In order to inform health authorities, this report aims to assess the evidence for theeffectiveness of parent education on vulnerable children or those children withbehavioural problems. It focuses on medium to long term effectiveness i.e. thatgreater than one year post intervention. The report also details the likely costsinvolved and discusses the overall balance of costs and benefits.

2 Background

2.1 Nature of behavioura l problems in children

Behavioural problems as referred to here are those behaviours, either mild or severewhich lead to inappropriate reactions, to conduct disorders or aggression. Excludedare more specific conditions such as hyperactivity and autism. One of the majordeterminants of problem behaviour in children is poor parenting, as characterised byharsh and inconsistent discipline, lack of positive parental involvement with the child,and poor monitoring and supervision1. This may account for as much as 30-40% ofthe variance in child antisocial behaviour2. Scott identified three main factorsinfluencing aggressive behaviour: parental rearing style, parent-child interactionpattern, and parental influence on children’s emotions and attitudes3. According to thesocial learning theory model, family members develop and sustain antisocial andaggressive patterns of behaviour in children through the use of ‘faulty contingencies’,or actions which are not contingent on the child behaviour. For example they maygive ‘positive reinforcement’ of bad behaviour or more potently ‘negativereinforcement’ of good behaviour. The child learns that aversive reactions producepay-off and escalation into a more severe coercive interchange occurs as the childlearns to respond to aversive acts through aversive counterattacks. Aggressive andantisocial children are more likely to interpret the intentions and actions of others ashostile and are more likely to use physical force and aggression as a solution tointerpersonal problems4.

2.2 Outcomes of behavi oural problems

Child behavioural problems, if not tackled early enough, often lead to persistentbehavioural problems later in life. For example, antisocial behaviour at age 13 hasbeen predicted by externalising behaviour at age 3 and behaviour problems at age 55.The number of convictions at age 30, as well as the seriousness of the crime has beenpredicted by peer-rated aggression at age 76.



2.3 The intervention – im portance of parent education

Parent education is a systematically and conceptually based programme, intended toimpart information, awareness or skills to the participants on aspects of parenting. Itaims to be both a solution to child behavioural problems and a means to preventprogression to more serious illness.

Informal parent support is currently provided by a variety of people such as laymothers, health visitors, social workers, teachers, and nursery nurses. They eitherprovide help and advice on an ad hoc, demand led basis or facilitate informal supportprogrammes. Both give tremendous support to parents and have been found to havepositive health and social outcomes7. There are also however more formal forms ofparent support programmes, which aim to give parents the skills to identify, define,and respond to problem behaviour. These programmes often use a group workapproach and are relatively structured and replicable. This report concerns itself inparticular with the latter.

3 Problem

3.1 Prevalence/incidenc e

Behavioural problems are the most important cause of disability in childhood8 with anestimated prevalence of 10-15%9. Data from the United States notes that aggression,conduct problems and antisocial behaviours make up to 35% of primary care childcontact time, 45% of community child referrals and are also the most frequent causeof child and adolescent clinical referral encompassing between one third and one halfof all child and adolescent clinic referrals10. Although such direct information is notavailable in the UK, discussions with primary care staff confirm the heavy burden thatsuch families bring, especially to Health Visitor time. Wallace et al give the following breakdown of prevalence of behavioural problemsand demand for services11:

Table 1 - Prevalence of behavioural problems in children.

Prevalence of relevant child and adolescent mental Health Disorders

Emotional disorders with onset in childhood 4.5-9.9% of 10 year olds 25-33% among clinic attendees

Conduct disorders 0.5-2.5% among children 2-8% among adolescents

District level surveys further demonstrate this heavy burden on government servicesand society. For example, according to the mental health needs assessment carried outin 1995 in one health authority area, Shropshire, of the 84,000 children under 16, 1 in5 will develop emotional behavioural disorders12.



3.2 Current service

To date, the service has been poorly co-ordinated and often piecemeal, split betweenhealth, social services and the voluntary sector. Smith in 199613 undertook anoverview of parent education provision in the UK. She made contact with knownservice providers and analysed data from 38 programmes. She found most were basedin only one location, and were small in scale, making provision patchy and oftenbased on the particular interest of certain individuals or groups. She classified theprogrammes according to approach and client group served. Table 2 gives examplesof formalised parent education training programmes. Most of these programmes fallunder two broad headings; those that focus primarily on changing children’sbehaviour (the behavioural approach) and those that address interpersonalrelationships within the family (the relationship approach).

Table 2 - Group parent education programmes based in the UK for children atrisk of or with behavioural problems.

Behavioural approach

Relationship approach

ABC of behaviour Coping with kids Effective parenting Handling children’s behaviour Managing difficult children Positive parenting Promoting positive parenting Working with parents for change Parent and child series

Newpin Parents against crime Family nurturing network Mellow parenting

3.3 Proposed service

The proposed service is that of co-ordinated parent education for children with or athigh risk of developing behavioural problems. The service will not cover thosechildren with severe problems requiring in-patient treatment or with a diagnosis oflearning difficulties, hyperactivity or autism. Nor will it address parents who arementally ill or who are known to be abusing their children. The interventions will bemainly group based parent education classes though specific home basedinterventions will also be considered, as will multidisciplinary programmes whereparent education plays a prominent part. Personnel involved may be health visitors butequally could be generic workers, volunteers, social workers, nursery nurses,community development workers, or child psychologists. Most programmes willinvolve the use of existing staff who will be appropriately trained. The costs includetraining and subsequent resource packs for staff as well as costs related toaccommodation for the parent education sessions. Training sessions for parentsnormally take place over a series of weeks and range from 10-15 sessions.



3.4 Problem in summary

Behavioural problems in children are widespread and can lead to extensive problemsin later life. At national level, parent education is being advocated within newgovernment initiatives as part of the means to addressing the increasing numbers ofchildren with behavioural problems and criminality in later life. At the local levelhealth authorities are being asked to consider parent education within the work ofHealth Visitors, and as part of multi-agency strategies. In order to decide whether tocommit resources, both local and national decision makers need evidence for theeffectiveness of parent education and an idea of the likely costs and benefits ofinvesting in it.

4 Aims of the review

4.1 General

The aim of this review is to inform the decisions of purchaser organisations as towhether to commit resources to the provision of parent education programmes. Though there have been reviews on the effectiveness of parent education in childrenwith behavioural and conduct disorders in the short term, there has been no systematicreview of the evidence that parent education works in the medium to long term. Thisreview will look therefore only at those studies where follow-up has taken place atleast one year post intervention.

4.2 Specific questions

Specifically the following questions will be addressed• What is the evidence that parenting education is effective in the medium to long

term?• What are the likely costs and benefits from an expansion of service provision in

this area?

4.3 Decision tree

A statement of the intervention and outcomes from parent education can be illustratedin a decision tree format (figure 1). As the above illustrates there are many importantoutcomes that can be considered. Here, the two main outcomes; child behaviour andparental mental health are considered as it was thought a priori that these were moreeasily measured and were best used to judge if overall parent education was effective.



Figure 1 - Decision tree for the main options and outcomes from parenteducation.

Improved child behaviour Unchanged or less parental stress

Improved child behaviour Increased/unchanged parental stress

Deteriorated/unchanged child behaviour Less parental stress

Parent education Deteriorated/unchanged child behaviour More parental stress

Children at risk of or with

behavioural problems

No parent education Improved child behaviour

Less parental stress

Improved child behaviour Increased/unchanged parental stress

Deteriorated/ unchanged child behaviour Less parental stress

Deteriorated /unchanged child behaviour More parental stress



4.4 Conclusions from ex isting reviews

There have been a number of previous reviews on the outcomes of parent education.Most found that differences in program philosophies, goals and evaluation designsmade it difficult to compare parent education programs and that, whenmethodological rigor and outcome validity are taken into account, few studies metspecified quality criteria. Despite this however, the majority of reviews drew positiveconclusions, with a few finding that results were either mixed or not statisticallysignificant14.

Two papers attempted a meta-analysis; Cedar & Levant 15and Serketich & Dumas16.Both found that the effect of parent education was positive on parent’s knowledge,attitudes and behaviour and on children’s self esteem and behaviour. Both sets ofpapers however only related to the short-term and the authors felt that an analysis oflong-term effectiveness would be important. The methodologies used in both meta-analyses were also complicated. Serketich & Dumas for example averaged effectsizes, corrected for bias and sample size and then analysed according to a number ofcontextual variables. Such complex analysis with the associated assumptions, thoughaiming to clarify the result, is misleading.

More recently, Jane Barlow, in conjunction with Sarah Stewart-Brown of the HealthServices Research Unit in Oxford, completed a systematic review of the short-termeffectiveness of parent training programmes in improving behaviour problems inchildren aged 3-10 years17 18. This concentrated primarily on the identification ofmeta-analyses and secondarily on the identification of first order evidence in the formof randomised controlled trials. Validity was assessed using the Journal of AmericanMedical Association criteria19. Here, no attempt was made to combine the results as itwas felt that the small number of effect sizes calculated and the heterogeneity of theindividual studies identified precluded such analysis. The conclusion of this reviewwas that in the short term parent-training programmes are effective in improvingbehaviour problems. Appendix I appraises and outlines the main results from thisreview.

The present review will complement Barlow’s work by looking specifically atmedium to long term outcomes, defined here as outcomes 1 year or more postintervention. Further, these studies will also be reviewed to look at the effects ofparent education on parental well-being and on societal and health services relatedoutcomes.

5 Methods

The methods undertaken in this review are those as outlined in the DES handbook.These are based on the guidelines set out in NHS CRD report 4. A protocol wasdeveloped and subjected to external review.



5.1 Criteria for included studies

Inclusion and exclusion criteria were defined in reference to the review question assummarised in table 3. These criteria include those on study design & quality.

Table 3 - Inclusion and exclusion criteria.

Inclusion ExclusionPopulation Children 0-16 years with behavioural,

anti-social or conduct disorders.At risk children from low incomefamilies or families with teen or singleparents.

Children with diagnosed psychiatricdisorders such as autism and attentiondeficit disorder or with problems severeenough to be in-patients.Low risk mothers.Child abusers.

Intervention Formal parent education or training.Could be in groups, at home or part ofa programme where parent education amajor part.

Where parent education is only one partof an extensive programme.Where the emphasis is on informalsupport rather than education.

Outcome Any outcome related to childbehaviour, parental self-esteem andstress and social outcomes.Outcome measure validated.Losses to follow-up under 30% unlessdemonstrated not to alter results.

Those outcomes that are not directlymeasurable e.g. telephone enquiriesonly.Outcome measure not validatedLosses to follow-up > 30%.

Study design &quality

Study design must include acomparison group.Sample size must be > 10.

No comparison group over time orcontrol group.Sample size < 10.

5.2 Search strategy

A comprehensive search involved fourteen databases, and an internet search. Fulldetails are in Appendix II. Citations were also checked from all articles received.Government publications of relevance were reviewed, and other organisationsinvolved in co-ordination and research in parent education were contacted forunpublished evaluation material. The breadth of the search enabled cost data papers tobe captured. Sources were searched from 1960 onward as before this time formalparent education had not been introduced .

5.3 Data extraction strat egy

Data was extracted from the databases onto an Excel spreadsheet to preventduplication of retrieval and to classify papers by the pre-determined inclusion criteria.On retrieval, data was recorded in a further Excel database to include qualityassessment criteria.

5.4 Quality assessment strategy

5 measures of validity on aspects of general design, selection, and detection bias wereaddressed as detailed in Appendix III. Every variable achieving the “high quality



standard” was awarded 1 point and thus lower scores indicate lower validity. Thevalidity scores are summarised in the results table.

5.5 Review analysis

Data extraction forms recorded the details of the included studies which were thentabulated in terms of their characteristics, quality, outcome measurement andsignificance of result. For the analysis however the heterogeniety of the studies interms of intervention, population and outcome measured, indicated that a formalmeta-analysis was inappropriate. It was however possible to comment on the overalldirection of effect and where data on means and standard deviations was available, tocalculate the magnitude of the effect either within groups or between groups using thefollowing formulae.

Effect size = Mean experimental group – Mean control groupStandard deviation control group

Effect size = Mean t 1 – Mean t 2 Standard deviation t 1

The outcome measures used unfortunately were numerous and mainly scales, makingit difficult to draw conclusions with regard to the practical effect of change on theindividuals involved or with regard to the magnitude of this effect. Thus theconclusions drawn are primarily based on the direction of effect and on the statisticalsignificance of this change.

5.6 Economic analysis

A review was undertaken of research literature on costs and previous economicevaluations. Unfortunately, there was insufficient data to undertake economicmodelling or to calculate costs per Quality Adjusted Life Years (QALYs) gained.However it was possible to identify the costs involved of introducing parent educationin Shropshire and to identify outcomes which maybe of relevance to assessing thebalance between costs and benefits in a cost consequences analysis.

6 Results

6.1 Effects and effective ness

6.1.1 Volume of material

4,000 references were identified from the formal search and 170 of these consideredin detail. After application of inclusion criteria 19 studies were finally included.Details of these studies can be found in Appendix IV. The included studies providedinformation on three groups of outcomes; child behavioural changes, parental well-being, and societal and health service outcomes which will be considered separately insections 6.2 to 6.4 below. Details of the characteristics and results will be consideredunder these sections though here we present some general points. 8 articles retrievedrelated to costs but only 3 contained any cost and outcome data. In none had aneconomic evaluation been carried out. Because of this, information on costs was also



obtained from other sources such as from groups carrying out parent educationprogrammes in this country. This is detailed in section 6.6.2.

6.1.2 Nature of intervention

Superficially, the nature of the parent education in the studies differed in the numberof sessions held, the teaching methodologies, if the education was individual or groupbased and the experience, training and background of the facilitator. However at apractical level the studies included all had a similar format in that they were sessionaland used standardised parent education packages. One important distinction howeveris where parent education formed part of a multisystem intervention where socialskills for example were also taught. These interventions were considered separately toascertain if excluding or including them affected the overall result.

6.1.3 Nature of population examined

The age range of children involved differed between studies, but all were eitherexhibiting behavioural problems or were at risk of developing them.

6.1.4 Nature of outcome measured

There was a wide range of outcomes reported in the studies. However for the analysis,only those most frequently used and best validated outcome measures were recorded.These are listed in the appendices under each outcome area. There was unfortunatelyvery little replication of outcome measures used which precluded direct summation ofeffect changes across studies.

6.1.5 Study quality and design

Randomisation of groups occurred in most studies or if absent, analysis of the groupsdemonstrated similarity of treatment and control groups at the start of the study. Allstudies had either a parallel or historical control group. Control groups were oftenadded into the experimental group after the initial sessions had been carried out socould not be directly used for comparison at long term follow-up. Instead a pre-intervention and follow-up comparison was made. In only five studies of childbehaviour and parental well-being were blinded observations carried out raising thepossibility of observer bias. The overall validity of included studies will be discussedin relation to the main effects seen under each outcome below. Each study has beenquality coded, though this is intended to give a crude ranking of the strengths andweaknesses of each study only.

6.2 Effects on child beh avioural changes

6.2.1 Characteristics

15 of the 19 studies provided information on the effect of parent education on childbehaviour. Details are given in Appendix V. As can be seen there is a high degree ofheterogeneity amongst the interventions, populations and outcomes measured in thesestudies as well as variability in their quality and hence their validity. However there



were 10 randomised controlled trials (RCTs) and 9 were classified as having a qualityof 4 or above so the quality of studies was high. The majority of studies had a follow-up time of 1 year, but four were of 2- 3 years, two 3-10 years and one had a follow-uptime of greater than 10 years.

6.2.2 Measures of child behavioural change used

There is a large range of outcome measures used across the studies and only threecommon measures. Furthermore the analysis of these outcome measures varies.Appendix VI outlines the different outcome measures used, and includes anexplanation of the meaning of the result. 8 of the 12 measures used were subject toobserver bias.

6.2.3 Results

Details of the results are given in Appendix VII but the key findings are summarisedin table 4.



Table 4 - Summary result table of effect of parent education on child behaviour.

Study Studydesign

Qualitycode

Intervention Direction ofeffect

GeneralSignificance ofresult

WebsterStratton ‘84

RCTi. 5 Video parent education Positive P<0.001

StrayhornWeidman‘90

RCT 5 Parent education Positive 2 of 4 measuresP<0.05

WebsterStratton &Hammond‘97

RCT 4 Parent education Positive P<0.001

Sutton ‘92 RCT 4 Parent education Positive P<0.001Van denBoom ‘95

RCT 4 Parent skills training Positive <0.01

Tucker &Gross ‘98

RCT 3 Parent training Positive 3 of 7 measuresP<0.05

Walker &Kavanagh’98

RCT 5 Parent educationPlus - School based work

Positive P<0.05

Trembley &Massi ‘95

RCT 4 Parent educationPlus - social skills training

No change Non significant

Mullin &Quigley

RCT 2 Parent educationPlus - self managementskills

Positive P<0.001

O’Donnel& Hawkins‘95

RCT 3 3 interventions:ClassroomChildParent

Positive 3 of 7P <0.05

Kadzin &Seigel ‘92

Compwithcontrol

3 Parent education, problemsolving skills, acombination

Positive P< 0.01 or< 0.001

WebsterStratton ‘90

PPSii. 4 Group, individual andvideo based parenteducation

Positive inall groups

P< 0.01 or< 0.001

Routh &Hill ‘95

PPS 4 Parent education Positive <0.001

Mullin &Proudfoot‘90

PPS 2 Parent education Positive P<0.001

Wahler ‘80 PPS 2 Parent education Positive Levels return tobaseline

i. Randomised controlled trialii. Pre-post intervention trial



As can be seen, 14 of the 15 studies had a positive result, 11 significantly so.In the study with a mixed result, Tremblay & Massi20, self rated disruptiveness waspositively reduced in comparison to control but not teacher rated disruptiveness,though neither showed a significant change. In one of the positive but non-significantstudies, Wahler et al21, effects were positive in the short term but returned to baselinein the longer term. Here there were differences between groups at the start of thestudy, the study was low in quality with a validity score of 2 and mothers socialcontact status was a major confounder. In another, Strayhorn and Wiedman22 theindependently assessed results where observer bias was less likely, were in factpositive, mainly significantly so, while parent assessments were non-significantlychanged. The final non-significant study, Tucker and Gross23 was lower in qualitywith a sample size of only 23.

It was possible to extract or calculate an effect size for the majority of studies and thisvaried between 0.03 and 2.2 across the different measures, though with so manydifferent outcome measures it was difficult to determine a magnitude of effect fromthis. However, 6 of the 15 studies used the Eyberg Child Behaviour Inventory (ECBI)designed to assess parental reports of behavioural problems in children. 5 of these 6showed improvements in behaviour at the 1% level. The one study which showed apositive but non significant change was Tucker & Gross which had quality flaws asexplained above. The effect size was positive from 0.4 to 1.9 for the intensity scaleand 0.17 to 2 for the frequency scale of ECBI. Another common outcome measurewas the Child Behaviour Checklist (CBCL) used in four studies. Here the effect sizewas 0.5 to 2.2, and all results were positive at the 1% level. The Dyadic Parent-childInteraction Scale (DPICS) was measured in 3 studies, was positive in all 3 andsignificantly so in 2 (P<0.05). The effect size was between 0.03 and 1.9. In the studywith a non-significant change (Van den Boom24) it was found that attachment status inthe mother was a major confounder. The DPICS is an independently assessed measureand therefore less open to bias.

Though the report does not set out to directly compare interventions, it is worth notingthat the results were in general more significantly positive where group parenteducation was the main intervention rather than individual work or work within alarger programme. The length of follow-up did not affect the general direction ofeffect nor did the quality of the study as assessed by the validity score. When onlythose results were considered where there was independent observation of behaviourthe results remained significantly positive..Overall therefore the results appear to be significantly positive for child behaviourimprovements lasting at least beyond one year of follow-up and possibly longer.



6.3 Effects on parental w ell-being


Appendix VIII summarises the characteristics of studies looking at parental well-being. 8 studies measure parental stress, mental state or attitude. 6 used a group basedintervention, 1 a multisystem intervention for teenage mothers and 1 individual parenttraining. Quality ranged from 2-5 with the majority coded 3 or 4.

6.3.2 Measures of parental well-being used

Again a wide range of measures had been used and again those best validated havebeen included here. Appendix IX gives details of these measures. All are self assessedscales.

6.3.3 Results

Details are given in Appendix X and the following table summarises the key findings.

Table 5 - Summary results table of effect of parent education on parental well-being.

Study Studydesign

Qualitycode

Intervention Direction ofeffect

Significance ofresult

Tucker &Gross

RCT 3 Parent education. Positive P 0.01

Mullin &Quigley ‘94

RCT 5 Parent education plusself management skills.

Positive P<0.01

Sutton ‘92 RCT 4 Parent education. Positive P<0.001Webster-Stratton &Hammond‘97

RCT 4 Parent training. Positive P<0.001

Kazdin &Siegel ‘92

Comp 3 Parent management, problemsolving, combined and control.

Positive 4 of 6P<0.05

Fuscaldo &Kaye ‘98

PPS 4 Teenage support programmewith parenting classes.

Positive 1 of 3P<0.001

Mullin &Proudfoot‘90

PPS 2 Parent education. Positive P<0.001

Baum &Forehand ‘81

PPS 2 Parent education. Positive P<0.01

All of the 8 studies had a positive effect, 6 significantly so. The variation in scalesmakes interpretation difficult but there were two common parental well-beingoutcome measures used; the Parental Stress Index (PSI) which measures the amountof stress a parent feels (a higher score reflects a decrease in stress) and the GeneralHealth Questionnaire (GHQ). Only two of the four studies which measured PSI were



significantly positive, the other two demonstrating a non-significant change.However, in one of the latter, Fuscaldo & Kaye25, the result was in fact significantlyimproved for the parent domain and in the other, Kazdin & Seigel 26, PSI wassignificantly improved when a combination of problem solving skills training andparent management training was applied. Effect sizes for PSI varied from 0.003 to1.4. Both the studies which measured GHQ were significantly positive but it was notpossible to calculate an effect size. Other outcome measures were also positive at the5% level. The only exception was the Coopersmith self-esteem score in Fuscaldo &Kaye’s study. The intervention in this study however involved a number ofprogrammes making it difficult to assess the impact of parent education alone.Overall, the result was significantly positive for most studies and did not differaccording to intervention, quality score or length of follow-up.

6.4 Societal and health s ervice outcomes


5 studies looked at societal and health service outcomes. The outcomes measures werepolice contacts, delinquency, drug use, college attendance, a delayed next pregnancy,child abuse, and health service use. Only 1-2 studies looked at each outcome and therewas a mix of different populations and interventions in the studies. Full details aregiven in Appendix XI.

6.4.2 Measures used

There were a number of different outcome measures used. Some were independentlyassessed using hospital, education or police records but others were based on selfreporting or unblinded observer rating. Details are given in Appendix XII.

6.4.3 Results

The following is a summary of the key findings , which are detailed further inAppendix XIII.



Table 6 - Summary result table of the effect of parent education on societal andhealth service outcomes.

Outcome area Study Intervention Outcome measure Directionof effect

Significanceof result

Police contact Bank &Marlowe

Parent training Offence rateTime in institutionPolice contacts

Positive NS

Tremblay &Massi

Parent training plussocial skillstraining

Court records Positive NS

Delinquency O’Donnel& Hawkins

3 intervention:ClassroomChild- Parent

DelinquencyGirlsBoys

Positive NS for girlsP<0.01 forboys

Tremblay &Massi

Parent training plussocial skillstraining

Delinquency Positive NS

Drug use O’DonnelandHawkins

3 intervention:ClassroomChild- Parent

Drug useGirlsBoys

Positive forgirls

P<0.05 forgirlsNS for boys

Delayedpregnancy

Britner &Reppucci

Parent education Delayed second child Positive P<0.01

Fuscaldo &Kaye

Teen parentingprogramme

Delayed second child Positive P<0.05

Furthereducation

Fuscaldo &Kaye


Completed education Positive P<0.05

Britner &Reppucci

Parent education Completed education Positive NS

Child abuse Britner &Reppucci

Parent education Reported rates ofchild abuse

Positive NS

Use of healthservices

Fuscaldo &Kaye


Regular use of healthcare

Positive P>0.05

Although all studies demonstrated a positive direction of effect, for many the changewas not significant. There were also a number of methodological flaws whichpreclude definite conclusions. There were firstly problems in the way that that someoutcome data was recorded. The crime rate figures for example only note thoseincidents recorded by the police (1-10% of total) and the child abuse figures are onlythose recorded by social services. Further, though some outcome measures such asdelay of subsequent pregnancy, completion of further education and appropriate useof health services, were based on independent records, many, such as delinquency anddrug use, depend on the records of the children or adolescents themselves or of theirteachers.



There are also large variations in the ages of the children in the studies though, asRuma notes, age may effect the degree of improvement in behavioural problems,which are more severe in older children, but should not effect the direction of effect27.The varied interventions however may affect outcomes, though there were not enoughstudies of any one type to draw conclusions. Most of these studies however involved along follow-up, highlighting the possibility of very long-term effects, conceivably upto 10-15 years.

Thus, overall, it is difficult to draw definite conclusions from the studies in thissection due to the variable populations studied, the variety of interventions and thelack of independently assessed outcomes. However results are promising for moreappropriate use of health services, for delay in subsequent pregnancy, and for uptakeof further education. Less clear are the effects on crime, delinquency, drug use andchild abuse.

6.5 Effects in summary and overall effectiveness

Although it has not been possible to draw the results together in a meta-analysis it ispossible to look at the general trend of the results and comment on them.Overall the effects of parent education seem to be positive with the majority of theincluded studies demonstrating significant benefits and no disbenefits.

The nature and quality of the included studies however highlight a number ofcriticisms. Firstly, it has been noted that many of the included studies havemethodological flaws, for example, few of the outcome measures are based on blindindependently observed measures. Secondly, the varied nature of the interventionsmakes it difficult to define what part of the intervention is effective and to generaliseacross the different studies. For example in the multisystem interventions it isimpossible to define which component of the intervention is related to whichoutcome. The varied nature of the populations of children in the studies is also aproblem. Thirdly, there are few common outcome measures to allow directcomparisons across studies and to quantify an overall effect size. Finally, the majorityof studies were based on programmes in the United States, though some were based inEurope, Ireland and the UK. This raises the question of the generalisability offindings.

Despite the above however it is still possible to draw conclusions. The inclusioncriteria ensured that those study designs highly susceptible to bias were eliminated.Also, when only those studies with a validity score of 5 out of 5 were included, andwhen only those outcomes that are based on blinded observations were considered theresults are still positive. Also, though interventions vary, they are still based ontraining of parents vis a vis their interactions with their children and even themultisystem interventions contain parent education as a major component. All havepositive results though we have not been able to demonstrate which particularcomponent of the interventions is most effective. Finally, though outcome measuresdiffer, when common measures were considered together a positive effect wasdemonstrated.



Thus, though there are a large number of criticisms that need to be considered, indrawing together the overall conclusions, it is possible to do so as long as the natureof the question is clear. Here one is looking for the overall direction of effect offormal training based interaction with parents of ‘at risk’ children of different agesand backgrounds in a number of different settings on a number of different outcomes.When this is considered, there is clearly a beneficial direction of effect on childbehaviour, and parental well-being, the positive effect on child behaviour also beingconfirmed by Barlow’s previous report on the short term benefits of parent education.Less clear is the direction of effect on societal and health service outcomes due to thelow numbers of included studies, the quality of these studies and their heterogeneity.There does appear to be benefits in terms of more appropriate use of health services, adelay in subsequent pregnancies, greater uptake of further education and lesssubsequent child abuse. Least clear is the direction of effect on criminality,delinquency and drug use.

6.6 Costs and health eco nomic analysis

6.6.1 Review of the literature

The literature search successfully identified three studies where cost data had beencollected. However, none of these studies carried out an economic evaluation butsimply collected costings, and all were carried out in the United States. Each of thethree studies assessed programme costs and proceeded to erroneously make claims ofcost-effectiveness, without carrying out an assessment of benefit costs. The findingsof these studies therefore, can only be interpreted as showing relative programme costand are not an assessment of cost-effectiveness. The three studies drew varyingconclusions. Cunningham28, for example found that community group-basedprogrammes were 6 times more expensive than individual clinic based programmes,yet, Seigert and Yates29 found that individual home based training was the leastexpensive approach. This may have been because of the different nature of theinterventions. In Seigert’s model, the number of clients in each group was small, therewas more than one therapist in each group, and the travel times to individuals waslow. Generally however it seems sensible to agree with Webster-Stratton30 who foundthat the group-based programme was less expensive as it involved less of thetherapist’s time.

These studies all come from the United States. Despite differences to the UK healthcare system, some information could still be important to an analysis of parenteducation programmes in the NHS. However, whilst some of the studies reportresource use data separately from unit cost data, the resources used in the delivery ofparent education programmes in the United States are very different to those involvedin any current or proposed service in the NHS. For example the travel costs andtraining costs are different. It is proposed therefore to base the cost section of the costconsequences analysis on cost data available locally within the UK. This will considerboth programme costs and costs to other parties.



6.6.2 Estimating programme costs

In reality there are five ways in which parent education programmes are provided inthe UK. These have been used to develop five models which can be applied whenthinking of the costs of setting up a parent education service. These do not necessarilyrelate to the models in the included studies.

In this case statutory refers to a government provided and run service and non-statutory to one provided by a voluntary or charitable organisation.1. Statutory centre based – run by government personnel in a government building.2. Statutory non-centre based – run by government staff but in a private building.3. Non-statutory (voluntary) – run by a charity in charity buildings.4. Statutory home based – run by government staff but in the client home.5. Non-statutory home based – run by non-statutory staff in the client home.

The models are based on a course run in 10 sessions over 20 hours. Allowances aremade for training and subsequent support of the group facilitators, paper andaccommodation resource costs, travel costs for facilitators, and the accommodationand staffing of a creche for the clients children. After discussions with facilitators inShropshire and with national programmes, it is assumed that the programme wouldideally be for approximately 15 parents though in reality only about 8 would attend.The costs are taken as costs in 1998/99 and relate to costs needed to set up parenteducation in a non-London district. Details of how the costs were calculated can befound in Appendix XIV, together with a breakdown for each model. Table 7 gives asummary.

Table 7 - Overall costs.

Programme Start up costs(Training and initialfollow-up)

Programme costs perclient per course (basedon 8 clients)

Model 1 – Statutorycentre based

£245 £154

Model 2 – Statutoryprivate centre based

£245 £230

Model 3 – Non-statutorycentre based

£225 £166

Model 4 – Statutoryhome based

£245 £1121

Model 5 – Non–Statutoryhome based

£225 £261

RangeAverage

£225- £245 £154 – £1121£353

As the above table shows, there is a range of costs related to the provision of parenteducation training, though all are relatively low. The start-up costs for training andinitial follow-up are very similar across programme structures but ongoing costs vary.Cheapest is group based parent education with Health Visitors working out ofstatutory buildings, followed by group parent education carried out by non-statutory



(voluntary) staff in their own premises. However if there is an opportunity cost to theuse of accommodation, group-based programmes run by Health Visitors are likely tobe similar in cost to a programme involving volunteers visiting clients at home.Which of the above five programme cost estimates is appropriate will depend on theexact nature of the programme proposed, in particular whether the programme will begroup-based or home-based, run by Health Visitors or voluntary sector staff, andwhether accommodation will be charged for.

A similar cost analysis has been carried out by researchers at the Centre for theEconomics of mental health looked at family centres31. They looked in detail at 7centres, some managed by statutory and some by non-statutory organisations andcalculated a cost for parenting support of £6.37 - £13.95 per hour. The cost here of£7.70 - £11.54 per hour for 8 clients is comparable. This also supports theexpectations of facilitators in Shropshire, that eight clients per group is a morerealistic estimate of attendance on which to assess cost per client of group-basedparent education programmes.

6.6.3 Health economics analysis

This report began with a description of the links between parental practices andbehaviour in childhood and adolescence, the links with parental self-esteem and withcriminality. Also described were the potential benefits of parent education withrespect of these outcomes and the beneficial effects in terms of both short and longterm health for the individual. Moreover the burden that children’s behaviouralproblems place on the health services were described. The report then went on, bycritically reviewing the literature, to explore the medium to long term effectiveness ofparent education in these areas i.e. child behaviour, parental well-being, health serviceuse and societal outcomes. Finally, the costs of running a parent education programmein the UK were calculated. Thus, though we are not able to carry out a cost benefitanalysis, we are able, by using the information from the studies reviewed, to speculateon the potential costs savings and benefits which a parent education programme maybring.

The inability to precisely quantify the effect size means it is inappropriate to performa cost-utility analysis to derive a cost per QALY, the usual aim of a DES report. Inlieu of this a cost consequences analysis outlines the costs likely to be incurred insetting up a service, the proven benefits, the cost savings likely to arise from thesebenefits, the proven disbenefits and the additional costs likely to arise from thesedisbenefits.

There are a number of additional costs to clients. There are the opportunity costsassociated with loss of earnings, loss of leisure time or loss of non-paid work timesuch as child care incurred as a result of attending sessions. The centre-basedprogrammes also incur travel costs. In terms of psychological costs there areprobably gains from group meetings but home visits may be made to those clientsunable for self-esteem reasons to come to a group.

The following table summarises these potential costs and benefits. The table looks atthe effect on costings for the NHS, for other statutory bodies and for society. Row 1



notes the costs involved in providing the service, row 2, the potential savings bylooking at the burden of costs that children’s behaviour brings, row 3, the potentialbenefits that introducing a programme of parent education may bring and row 4 thepotential disbenefits from the service.

Table 8 - A summary of available information relating to cost savings andpotential benefits of parent education.

NHS Other statutorybodies

Society

Costs of providingservice.

(average of £353 perclient per course)

Health Visitor time.Accommodation.

Staff time.Accommodation.

For clients;Travel time;Leisure time;

Loss of earnings.Potential cost

savingsBy looking at burdenof costs of children’sbehavioural problems

can determinepotential cost savings

35% of GPconsultations;

45% of communityhealth referrals;50-65% mentalhealth service

referrals1;Inappropriate use ofhealth services and

casualty departmentse.g. high numbers of

accidents andpoisoning frequently

seen in suchchildren32.

High social servicescase load.

Large number ofchildren in care.

Need for specialisteducation provision.

High use ofgovernment fundedvoluntary bodies.

Delinquency.Crime.

Drug use.

Potential benefits ofintroducing PET

Improved childbehaviour and hence

less need forsecondary referral.

More appropriate useof general health

services.Delayed subsequent

pregnancy.Improved parental

well-being.

Higher rates offurther education

uptake.Less child abuse anda lowering of socialservices caseload.

Less delinquency.Less crime.

Less drug use.

Disbenefits Opportunity cost ofstaff involved andaccommodation

costs.

Opportunity cost ofinvolved staff andaccommodation.

Stigma of attendingclasses.

1 Data from USA



It is not possible to say from the literature exactly what percentage of such childrenwill be helped by parent education but it is possible to say that behaviour is improved.To assume this translates to costs savings to the NHS, to other statutory bodies and tosociety as a whole would be speculative, but the potential for such savings should notbe ignored. Although parent education involves an additional cost to the NHS, it islikely that the use of other services by both the child and the parent will decrease ifthe parent education is effective. Table 8 suggests those cost savings to primary andsecondary health services, to social services, education services and to the voluntarysector. Thus, though it has not been possible to carry out a full economic evaluation inthis context due to lack of data, it is possible to say that for the relatively smallaverage cost of £353 per client per course, parent education has the potential toproduce large benefits and costs savings with few disbenefits.

6.7 Quantification of cos t utility

The marginal cost of training one extra client ranges from £154 for group based to£1121.25 for home based interventions, though with greater than 15 clients a newcourse needs setting up with additional accommodation and staff training costs. Ifone takes these costs and projects how much health benefit would need to occur inorder to achieve a key threshold cost per QALY of £20,000, the QALY gain wouldneed to be in the region of 0.01 to 0.06. Considering only those benefits that are wellestablished, over just a one year period it seems highly plausible that the net benefitoccurring for children and their parents combined would easily reach and exceedthese levels. On this basis, although it has not been possible to precisely quantitybenefit and so derive a measure of cost utility, it seems likely that the cost per QALYis below £20,000.



7 Conclusions

Aggressive and anti-social child behaviour, drug use, crime and delinquency areincreasing concerns in western countries and place a huge burden on both governmentservices and on society. Furthermore, there is also much evidence to link parenting toearly child behaviour and hence later to delinquency and criminality 33 34. Anyintervention to address poor parenting and hence tackle these problems has hugepublic health implications but must be carefully assessed. This review sets out toreview the evidence for the effectiveness of parent education to improve early childbehaviour, parental well-being and possible to subsequently decrease levels ofdelinquency.

The main problem encountered in doing this is that, despite including only the bestquality studies, the overall validity of the studies reviewed is still questionable. Thelack of a direct control group at the long-term follow-up date, and the fact thatoutcomes are often parent and teacher recorded rather than independently assessed aretwo important flaws in the included studies. Secondly, the variety of ways ofquantifying changes and the heterogeneity of the studies made it impossible toquantify the effect size across studies and hence difficult to draw conclusions on thelikely magnitude of effect of introducing a parent education programme and on thelikely cost savings. Thirdly, it is important to also consider the generalisability of theincluded studies many of which are based on programmes in the United States to theUK setting. Finally the studies reveal a plethora of different interventions andpopulations studied making it difficult to assess which particular intervention worksfor which population group.

Despite these problems however, and despite the degree of heterogeneity amongst theincluded studies, this review has demonstrated that it is possible to look at the studiesoverall. Thus a clear question is given, strict inclusion and exclusion criteria appliedand the overall direction of effect noted under each outcome section. Conclusions aregiven in each section but overall the results show that the effect of parent education onboth child behaviour and parental well-being is positive and this effect is sustained inthe medium to long term i.e. greater than 1 year. The potential benefits to societyhowever is more difficult to demonstrate due to the smaller number of studiesinvolved and the greater methodological flaws in these studies though the potential ofbenefits have been demonstrated.

The cost consequences analysis further demonstrates the relatively low costs involvedin providing a parent education service when set against the potential cost savings andshort and long term benefits to both the NHS, other statutory bodies and to society asa whole.

In relating the results of this systematic review and cost analysis to the originalproblem of whether health care commissioners should support teaching parentingskills, it is immediately acknowledged that existing research does not provide acomplete answer. However it does provide encouragement to those contemplatingsuch activity provided they stick to the population groups, settings, and interventionswhich have been evaluated. For those sceptical about the value of such activities, it is



unlikely that the results of this review will be wholly convincing. In this case thereport identifies where uncertainty exists, namely better estimation of effect sizes,particularly the global impact. The onus in this case is on rigorous research.

The aim of this review was to inform the decisions of purchaser organisations as towhether to commit resources for parent education programmes and two specificquestions were asked. The answers to these questions can now be given.

• That there is evidence that parent education is effective in the medium to longterm

• That the likely costs and benefits to be incurred from expansion of this service aremost likely to be in favour of parent education.

Health authorities therefore may invest in parent education but any programme shouldalso include a research and evaluation component.



8 Appendices

I Results and appraisal of previous review.

II Search Strategy.

III Quality assessment.

IV Included studies.

V Characteristics of child behaviour outcome studies.

VI Outcome measures for child behaviour outcome studies.

VII Results of child behaviour outcome studies.

VIII Characteristics of parental well-being outcome studies.

IX Outcome measures for parental well-being.

X Results of parental well-being.

XI Characteristics of societal and health service outcome studies.

XII Outcome measures for societal and health service outcomes.

XIII Results of societal and health service outcomes.

XIV Cost analysis and models for cost analysis.



Appendix I

Main results and appraisal of previous review by Jane Barlow and SarahStewart Brown

Appraisal The form of this review followed that recommended by JAMA and was rigorous.Extensive databases were searched though searches were restricted to publicisedmaterial introducing the possibility of publication bias.

Of 245 studies identified, only 16 were included. Criteria included randomisation, theuse of some form of control, a standardised outcome measure and a sample size >10. Not included however was high loss to follow-up which in 10 of the 16 studies waseither not accounted for or was high. This could result in an overestimation of theintervention effect. The lack of independent observers in the included studies was afurther problem but the potential effect of this was discussed in the analysis. Usefultables summarised the critical appraisal of papers and the main characteristics andresults of studies.

Results Results were largely positive. They concluded that group based programmesimproved the behaviour of young children compared with no-treatment controls orwaiting list control groups, as measured by both parent reports and independentobservations of children’s behaviour. The effect size ranged from 0.3-1.8 for parentreported child behaviour outcome measures and 0.2-0.9 for independent observationsthough two studies failed to confirm the improvements in children’s behaviourreported by parents.



Appendix II

Search strategy - Outcomes searched for

The following outcomes were searched for:

Child• Change in behavioural levels• Parent- child interaction Parent• Change in self-esteem• Depression and anxiety levels.• Satisfaction of parents• Confidence of parent Social• Change in delinquency levels and criminality.• Further education uptake• Criminality Other• Fall in hospital admissions• Increase in immunisation status• Fall in A&E attendance• Improvement in school or college attendance.• Change in referral patterns.• Delay of second pregnancy.

Mesh terms The core terms were: PARENT and (TRAINING or EDUCATION or GROUP) (CONDUCT or BEHAVIO*) AND (PROBLEM or DISORDER*) Then according to outcome e.g. Text word – crime, homelessness, unemployment,school-attendance, mental health, fall in hospital admissions, immunisation status,A&E attendance, children in care, child protection register, adolescent emotionalbehavioural disorders, delinquency, education, suicide and parasuicide.



Databases The following databases were searched: Biomedical Science databases:• Medline• Embase• PsycLit• ERIC• CAB Abstracts• IBSS• ISI• CINAHL• Cochrane

Social Sciences and general reference databases:• Dissertation Abstracts• Social Science Citation Index• Healthstar• Sociological Abstracts• ASSIA



Appendix III

Quality assessment criteria

Validity criteria Comment Observer bias? Independent or blindedobservation?

High quality – Observers blinded or methodology tominimise observer bias. Low quality – Observers not blinded.

Detection bias? Was the study conductedprospectively?

High quality – Prospective or retrospective where all keyelements measured before and after intervention using clearcriteria defined a priori. Low quality – Studies where key outcomes not measuredbefore and after intervention.

Selection bias? Was the method of selection ofcases identified and appropriate?

High quality – Groups randomised or if not randomisedshown to be similar. Low quality – Groups different at start in key indicators.

Selection bias? Were groups similar at start?

High quality – Groups randomised or if not randomisedshown to be similar. Low quality – Groups different at start in key indicators.

Selection bias? Any possible confoundersexplored?

High quality – Confounders sought and investigated for inanalysis. Low quality – Obvious confounders not considered andpotentially problematic.



Appendix IV

Included studies

Bank & Marlowe 1991 Bank L, Marlowe H, Reid JB, Patterson GR, Weinott MR. A comparative evaluationfor families of chronic delinquents. Journal of Abnormal Child Psychology1991;19(1): 15-33

Baum & Forehand 1981 Baum CG, Forehand R. Long-term follow-up assessment of parent training by use ofmultiple outcome measures. Behaviour Therapy 1981;12:643-652.

Britner & Repucci 1997 Britner PA, Repucci ND. Prevention of child maltreatment: Evaluation of a parenteducation program for teen mothers. Journal of Child and Family Studies 1997;6(2):165-175.

Fuscaldo & Kaye 1998 Fuscaldo D, Kaye JW, Phlliber S. Evaluation of a program for parenting. Families inSociety 1998;1:53- 61.

Kazdin & Siegel 1992 Kazdin AE, Siegel TC & Bass D. Cognitive problem-solving skills training and parentmanagement training in the treatment of anti-social behaviour in children. Journal ofConsulting and Clinical Psychology 1992;60(5):733-747.

Mullin & Quigley 1994 Mullin E, Quigley K & Glanville B. A controlled evaluation of the impact of a parenttraining programme on child behaviour and mothers general well-being. CounsellingPsychology Quarterly 1994;7(2):167-179.

Mullin & Proudfoot 1990 Mullin E, Proudfot R & Glanville B. Group parent training in the Eastern Healthboard: programme description and evaluation. The Irish Journal of Psychology1990;11(4):342-353.

O’Donnel & Hawkins 1995 O’Donnel J, Hawkins JD, Catalano RF, Abbott RD, Day LE. Preventing schoolfailure, drug use and delinquency among low-income children: Long termintervention in elementary schools. American Journal of Orthopsychiatry 1995;65(1):87-100.

Routh & Hill 1995 Routh CP, Hill JW, Steele H, Elliot CE, Dewey ME. Maternal attachment status,psychosocial stressors and problem behaviour: follow-up after parent training coursesfor conduct disorders. Journal of Child Psychology & Psychiatry & Allied Disciplines1995;36(7):1179-1198.



Strayhorn & Weidman 1991 Strayhorn JM, Weidman CS. Follow-up one year after parent-child interactiontraining: effects on behaviour of pre-school children. Journal of American AcademicChild Psychiatry 1991;30(1):138-143.

Sutton 1992 Sutton C. Training parents to manage difficult children: A comparison of methods. Behavioural Psychotherapy 1992;20:115-139.

Tremblay & Massi 1995 Tremblay RE, Pagini-Kutz L, Masse LC, Vitaro F, Pihl Ro. A bimodel interventionfor disruptive kindergarden boys: Its impact through mid-adolescence. Journal ofConsulting and Clinical Psychology 1995;63(4):560-568.

Tucker & Gross 1998 Tucker S, Gross D, Fogg L, Delaaney K, Lapporte R. The long-term efficacy of abehavioural parent training intervention for families with 2 year olds. Research inNursing and Health 1998;21:199-210.

Van den Boom 1995 Van den Boom DC. Do first year intervention effects endure? Follow-up duringtoddlerhood of a sample of Dutch irritable infants. Child Development 1995;66:1798-1816.

Wahler 1980 Wahler RG. The insular mother: Her problems in parent-child treatment. Journal ofApplied Behaviour Analysis 1980;13:207-219.

Walker & Kavanagh 1998 Walker HM, Kavanagh K, Stiller B, Golly A, Severson HH, Feil EG. First steps tosuccess: An early intervention approach for preventing school antisocial behaviour.Journal of Emotional and Behavioural Disorders 1998;6(2):66-80.

Webster–Stratton & Hammond 1997 Webster-Stratton C, Hammond M. Treating children with early onset conductproblems: A comparison of child and parent training interventions. Journal ofConsulting and Clinical Psychology 1997;65(1):93-109.

Webster-Stratton 1984 Webster-Stratton C. Randomised trial of two parent-training programs for familieswith conduct disordered children. Journal of Consulting and Clinical Psychology1984;52(4):666-678.

Webster-Stratton 1990 Webster-Stratton C. Long-term follow-up of families with conduct problem children:From pre-school to grade school. Journal of Clinical Child Psychology1990;19(2):144-149.



Appendix V

Characteristics of studies looking at child behaviour

Study Design Qualitycode

Population Intervention Comment

Walker &Kavanagh1998

RCT No controlgroup atlong-termfollow-up

5 46 at risk kindergardenchildren with early signs ofantisocial behaviour. Follow-up – 2 years.

2 modules, School intervention and parenttraining.

Good study but strictlycontrolled entry criteriaand much school basedwork questionsgeneralisability.

Webster-Stratton1984

RCT 5 35 Children 3-8 year oldswith conduct problems. Follow-up – 1 year.

Individual and group video parenteducation (PET): - Control group (CON) - Individual therapy (IT) - Video group therapy (VGT)

Good quality study.

Strayhorn Wiedman1990

RCT 5 50 low income pre-schoolchildren with externalisingbehaviour. Follow-up – 1 year.

Group parenting instruction andindividual modelling.

Good quality study Control group andindependent observers.

Webster-Stratton1990

Comparison Of 3methods No controlgroup.

4 134 Pre-school children 3-7 years old with conductdisorders. Follow-up –3 years.

3 groups of parent education: - Self administered videotapemodelling (IVM) - Therapy led discussion group(GD) - Therapy led group discussionvideotape modelling (GDMV)

No independentobservation ofchildren’s behaviour.

Webster-Stratton &Hammond1997


4 Conduct problems in 9718-24 months olds. Follow-up – 1 year.

4 equal groups: - Parent training (PT) group - Child training (CT) group - Combined (PT+CT) group - Control group

Both parent records andindependentobservations made.





Sutton1992


4 37 antisocial pre-schoolchildren. Follow-up – 12-18 months.

4 comparative parent educationprogrammes: Group, home visit,telephone, waiting list control

Small numbers in eachgroup. Independent observerused.

Routh &Hill 1995

PPS 4 37 Children with conductdisorder. Follow-up – 13-43 months.

Group parent managementtraining.

One group onlyfollowed over time.

Trembley& Massi 1995

RCT 4 319 Disruptivekindergarden children. Follow-up – long term tillaged 10-15 years.

Social skills and parent education. Home based parenttraining with schoolbased social skillstraining.

Van denboom1995

RCT 4 82 irritable infants (as assessed by behaviourscore) from low incomefamilies. Follow-up – 3.5 years.

Home based skills training. Dutch study with theaim of enhancingmaternal sensitivity.

Tucker &Gross1998

RCT

3 46 21-36 month old infantsdisplaying negativebehaviour. Follow-up – 1 year.

Behavioural parent training. Most outcomes (bar 1)parent recorded.

Kazdin &Siegel1992

Comparisonof 3 typesof parenteducationwith control

3 97 Severely antisocial 7-13 year olds. Follow-up – 1 year.

3 groups given individual therapy:- Problem solving skills training (PSST)- Parent management training

(PST- Combined (comp)- Control

No control group Mixture of parent andteacher assessment. No independentmeasures.





O’Donnel&Hawkins1995

RCT 3 177 low income urbanchildren. Follow-up – 6 years.

Seattle social development project. School based: -Classroom intervention -Child intervention -Parent intervention

A high risk sub-groupwere analysedseparately who werefrom low incomefamilies.

Mullin &Proudfoot1990

Pre and postinterventionstudy.

2 94 Children with conductdisorder. Follow-up – 1 year.

Parent behavioural training. Study particularlyfocused on attachmentbehaviour.

Mullin &Quigley1994

RCT No controlgroup atlong-termfollow-up.

2 79 children with Conductdisorders of 3 months – 14yrs. Follow-up – 1 year.

Group behavioural modificationand self management skills forparents.

All outcome measuredself administered. Control group lessdisturbed at baseline inone measure.

Wahler1980

PPS 2 18 Isolated, low incomefamilies. Follow-up – 1 year.

Individual parent training. Studies main aim tolook at effect of mothersinsularity on outcomes.

Abbreviations used in tables. RCT – Randomised controlled trial. PPS – Pre and post intervention study.



Appendix VI

Child related outcome measures used

Outcome measure Description of measure Expected changein measure forpositive change

Has measure beenvalidated?

Child Behaviour Checklist(CBCL).

Eyberg Child BehaviourInventory (ECBI)*.

Behar Pre-school Behaviour Questionnaire(PBQ).

Child Behaviour Questionnaire(CBQ)

118 items listed on a 0-2 scale that constitute multiplebehaviour problem scores. Can get a total behaviour score ora social score.

Designed to assess parental report of behaviour in children.36 problem behaviours measured on 2 measures; frequencyof occurrence (F) and identification as a problem (I).

Checklist of the DSM-III- R Criteria for oppositional andattention deficit disorders. 3 subscales:hostile-aggressive,anxious, and hyperactive-distractible.

8 items on child behaviour.

Decrease (except; socialcomponent)

Decrease

Decrease

Decrease

Y-Achenbach &Edelbrock

Y – Robinson et al1980

Y – Behar 1977

Not independent

* Classified as ECBI(I) for intensity of behaviour and ECBI(F) for frequency of behaviour,



Outcome measure Description of measure Expected change inmeasure for positivechange

Has measurebeen validated?

Daily Parent Record (PDR)

Wally Child Social ProblemSolving Detection (WALLY)

Dyadic Parent-childInteraction (DPICS)

Early Screening Project (ESP)

Academic Engagement Time(AET)

Standard Observation Code (SOC)

Social BehaviourQuestionnaire

Seattle Development Item andScale Dictionary

23 behaviours reviewed in previous 24hrs. Requirescalling the parent daily.

Assesses quality and quantity of problem solving.

29 categories covering child and parental behaviour.

Systematic screening for behavioural disorders.

Measure of classroom behaviour.

Direct observation of child and family membersbehaviour.

Measure of disruptiveness.

Intervention and outcome measures.

Decrease

Decrease

Decrease in negative,increase in positive.

Adjusted – increase Maladjusted – decrease

Increase

Decrease

Decrease

Multiple scale – mostdecrease

Y – Foster andRobin 1988

Y – Webster-Stratton 1990

Y – Robinson &Eyberg 1981

Y – Walker &Seversen 1990

Y - Rich & Ross1989

Y – Wahler et al1976

Y – Tremblay etal 1991 Y – Seattle devproject – Unpublished



Outcome measure references

Achenbach TM, Edelbrock CS. Manual for the child behaviour checklist and revised childbehaviour profile. Burlington, VT: University Associates in Psychiatry, 1991.

Robinson EA, Eyberg SM, Ross AW. The standardisation of an inventory of child conductproblems. Journal of Clinical Child Psychology 1980;9:22-28.

Behar LB. The Preschool Behaviour Questionnaire. Journal of Abnormal Child Psychology1977;5:265-275.

Foster, Robin AL. Family conflict and communication in adolescence. In Mash EJ, Terdal LG(eds). Behavioural assessment of childhood disorders (2nd ed. 717-775). New York: GuifordPress, 1988.

Webster-Stratton C, Hammond M. Treating children with early onset conduct problems: Acomparison of child and parent training interventions. Journal of Consulting and ClinicalPsychology 1997;65:93-109.

Robinson EA, Eyberg SM. The Dyadic Parent-Child Interaction Coding system:Standardization and validation. Journal of Consulting and Clinical Psychology 1981;9:22-29.

Walker HM, Seversen I, Feil E. (1994). The ESP; a proven child-family process. Laynum co-sopris west, 1994.

Rich H, Ross S. Students time on learning tests in special education. Exceptional Children1989;55(6):508-515.

Wahler RG, House AE, Satmbaugh EE. Ecological assessment of child problem behaviour: Aclinical package for home, school and institutional settings. New York: Pergamon Press,1976.

Tremblay RE, McCord J, Boileau H, Charlebois P, Gagnon C, Le Blanc M, Larivee S. Candisruptive boys be helped to become competent? Psychiatry 1991;54:148-161.



Appendix VII

Results of studies assessing child behavioural changes

Study Outcome measure Measure att1 or control

Measure at t2orintervention

Difference Effect size Directionof effect

Significance Independentlyassessed

Y/N Webster-Stratton ‘84

CBI VTG CBI IT ECBI ECBIf VGT IT ECBIi VGT IT Teacher BPQ VGT IT DPICS Total deviance – VGT - IT Total noncompliance- VGT - IT

61.67 t1 71

19.47 22.37 144 166.62 - -

15.9 12.28 6.43 7.09

36.33 t2 34.44

8.47 6.56 104.27 117.38 17.43 15.73

1.9 1.44 1.77 1.97

25.34 36.56

11 15.81 39.73 49.24 - -

14 10.84 4.66 5.12

1.4 1.1

1.44 1.9 2.0 1.7 - -

1.12 0.8 1.22 0.77

Positive P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001 P<0.001

P<0.01 P<0.05 P<0.001 P<0.01

Some CBCL & ECBI

Parent orteacher

assessed.

DPICS Independently

assessed.

StrayhornWeidman ’90

Parent Behar Composite Teacher Behar Composite Hostile Hyperactive

43 Control

3025 3125 3025

34 Intervention

25 25 25

9 5 6 5

- - - -

Positive NS P<0.05 NS P<0.05

Yes - Some Independently

teacherassessed.







Y/N WebsterStratton &Hammond‘97

ECBI mother ECBI father CBCL mother CBCL father DPICS Deviance with mothers Deviance with fathers Positive effect with mothers Positive effect with fathers WALLY PDR (-) PDR (+)

154.05 t1 148 67

62.88

18.95 16.73 11.34 9.23 5.68

10.67 13.24

119.28 t2 108.31 55.08 53.5

8.75 6.46 20.5

25.36 7.68 3.88 4.4

34.77 39.69 11.92 9.38

10.2 10.27 9.16

16.13 2.0

6.79 8.84

1.96 2.36 0.77 1.1

0.56 1.1

0.95 1.2 0.9 1.9 1.5

Positive P<0.001 P<0.001 P<0.001 P<0.001

P<0.001 P<0.01 P<0.001 P<0.01 P<0.001 P<0.001 P<0.001

Some – Homeobservations

(DPICS)independently

assessed

Sutton ‘92 CBQ Home situation

- t1 -

- t2 -

- -

- -

Positive P<0.001 P<0.001

No- Parent

Van denBoom ‘95

Attachment status DPICS Positive - Negative

Control

0.06 0.06

Intervention

0.24 0.02

0.18 0.04

0.23 0.03

Positive

NSNS

Yes Independently

blinded.

Tucker &Gross ‘98

ECBI (I) mother reported ECBI (f) mother reported

108.83 t1 3.33

101.92 t2 2.58

6.92 0.75

0.44 0.17

Positive P<0.05 NS

No Parent

assessed. Walker &Kavanagh ’98

AET ESP Adaptive Maladaptive CBCL Aggression Withdrawn

62.5% t1 21.96

32.58 20.33 7.04

83.7% t2 26.72 23.83 14.55 6.11

21.17% 4.76 8.75 5.78

0.93

2.2 1.21 1.3

0.83 0.5

Positive P <0.05 P<0.01 P<0.01 P<0.01 P>0.05

No Teacher or

observer rated.







Y/N Trembley &Massi ‘95

Disruptiveness - - - - Nochange

NS No Parent

assessed.

Mullin &Quigley

ECBI(f) ECBI(I)

80.72 t1 17.95

63.25 t2 7.6

17.47 10.35

No ES but Exp groupimprovedby 32%,

control by2.8%.


No Parent

assessed.

O’Donnel &Hawkins ’95

Conventional involvement Girls Boys Social skills Girls Boys Rewards Girls Boys Social Girls Boys

t1 2.63 2.6

1.78 1.98

3.52 3.35

1.29 1.47

t2 2.45 2.66

1.8 1.63

3.43 3.16

1.49 1.46

0.18 0.06

0.02 0.35

0.09 0.19

0.2 0.02

0.14 0.05

0.05 0.7

0.14 0.19

0.34 0.02

Positive

NS NS

NS P<0.05

P<0.05 P<0.1

NS ?

No Self andteacher

assessed.







Y/N Kadzin &Seigel ’92

CBCL – Total PSSM PMT Combined CBCL ( Social) PSSM PMT Combined

t1 72.0 69.8 69.6

34.5 32.7 36.7

t2 63.9 66.1 56.2

39.4 39.8 43.5

8.1 3.7

13.4

4.9 7.1 6.8

0.96 0.5 1.8

0.65 0.75 0.98

Positive

P<0.001 NS

P<0.001

P<0.01 P<0.01

P<0.001

No Teacher and

parentassessed.

Webster-Stratton ‘90

CBCL - GDVM –mother Father GD – Mother Father IVM – Mother Father

68.56 t1 65.5 66.52 65.08 66.03 67.6

56.4 t2 48.58 62.68 56.92 59.35 57.95

12.16 16.92 3.84 8.16 6.68

10.35

1.66 2.22 0.39 1.42 0.65 1.57


NS P<0.01 P<0.01 P<0.01

No Parent

assessed.

Routh & Hill‘95

ECBI(I) ECBI(f)

152.8 t1 18.4

128.8 t2 11.3

24 7.1

- -


No Parent

assessed. Mullin &Proudfoot ‘90

ECBI(I) ECBI (f)

71.13 t1 12.76

57.18 t2 3.25

13.95 9.51

- -


No parentrecords.

Wahler ‘80 Standard observation codeSOC

3.95 2.24

4.07 2.23

0.12 0.01

0.03 0.002

Positive NS No Self report.



Appendix VIII

Characteristics of studies looking at parental well-being



Mullin &Quigley1994

RCT 5 79 children with conductdisorders aged 3 months –14 years. Follow-up 1 year.

Group behavioural modificationand self management skills forparents.

All outcome measuresparent recorded.

Sutton1992

RCT 4 37 anti–social pre-schoolchildren. Follow-up 12-18 months.

4 comparative parent educationprogrammes: Group, health visitor,telephone, waiting list control.

Small numbers in eachgroup.

Fuscaldo& Kaye1998

PPS 4 31 Teenage mothers. Follow-up –2 years.

Teen parenting programme with:- Infant toddler centre- Parenting classes- Parent support group- Life skills training- Jobs skills training- Tutoring- Mentoring

Multisystemsprogramme with manycomponents. Cannot record separateeffect of parenteducation component.

Webster-Stratton &Hammond1997


4 Conduct problems in 9718-24 months olds. Follow-up – 1 year.

4 equal groups: - Parent training (PT) group - Child training (CT)group. - Combined (PT+CT) group. - Control group

Both parent records andindependentobservations made.

Tucker &Gross1998

RCT 3 46 21-36 months oldinfants displaying negativebehaviour. Follow-up – 1 year.

Behavioural parent training. Most outcomes parentrecorded.





Kazdin &Siegel1992

Comparisonof 3 types

3 97 Severe anti–social 7-13 year old children. Follow-up – 1 year.

3 groups:- Problem solving skills training (PSST)- Parent management training

(PMT)- Combined (comp)- Control

Parent recorded results.

Mullin,Proudfoot 1990

PPS 2 94 Children with conductdisorders. Follow-up – 1 year.

Group parent behavioural trainingprogramme.

Study focuses onattachment behaviour.

Baum &Forehand1981

PPS 2 34 Non-compliant children. Follow-up 1 - 4.5 years.

Individual parent training. Home observation aswell as parent recordsrecorded.



Appendix IX

Parent related outcome measures used in tables

Outcome measure Description of outcome measure

Expected changein measure forpositive change

Validity

Beck Depression Inventory(BDI) Rosenberg Self-esteemInventory (RSEI) General Health Questionnaire(GHQ) Texas Social BehaviourInventory (TSBI) Parental Stress Index (PSI)

Coopersmith Self-esteemScore Adult – Adolescent ParentingInventory (AAPI) Parent Attitude Test

Severity of depressive symptoms. 10 items scores 1-4 on self esteem. 120 item scale assessing sources of stress to parents Self administered screening test to assess emotional morbidity. 30 questionson a 4 point scale Measure of social competence. 16 items scores 1-4. 120 item items measuring parental stress related to childbearing. 4 sub-scales are combined into a maximum score of 116. 32 items in 4 areas. Completed by parent – 3 scales – home attitude, behaviour rating andadjective checklist scale.

Decrease Increase Decrease Increase Decrease Increase Increase Decrease

Y – Lloyd andAdidin 198535 No independentvalidation Y –Goldberg197836 No independentevaluation Y – Adibin 199037 Y – Foster andRobin 1988. Not independentlyevaluated Y – Cowen &Huser 197038



References for parental well-being outcome measures Lloyd BH, Abidin PR. Revision of the parenting stress index. Journal of PediatricPsychology 1985;10:169-177.

Goldberg D. Manual of the General Household Questionnaire. Windsor: Nfer-Nelson,1978.

Adibin PR. Parenting Stress Index (3rd edition). Charlottesville. VA: Pediatric PsychologyPress, 1990.

Foster, Robin AL. Family conflict and communication in adolescence. In Mash EJ, TerdalLG (eds). Behavioural assessment of childhood disorders (2nd ed, 717-775). New York:Guiford Press, 1988.

Cowen EL, Huser J, Beach DR, Rappaport J. Parental perception of young children andtheir relation to index of adjustment . Journal of Consulting and Clinical Psychology1970;34:97-103.



Appendix X

Results of studies assessing changes in parental well-being

Study Outcomemeasure

Measure att1 or control

Measure att2 orintervention

Difference Effect size Direction ofeffect


Y/N Tucker &Gross

PSI 112.17 t1 100.58 t2 11.59 0.4 Positive P<0.05 No Self assessed.

Mullin &Quigley ‘94

TSBI RSEIGHQ

33.62 t1 29.85 6.62

43.25 t2 33.42 1.53

9.63 3.57 5.09

% improvement TSBI 19.36 (2.57) RSEI 11.83 (0.54) GHQ 75.98 (3.31)


P<0.001

No Self assessed.

Sutton ‘92 PSI - - - - Positive P<0.001 No Self assessed.

Webster-Stratton &Hammond 97

PSI (M)PSI(F)

142.46 t1 125.47

117.13 t2 106.73

25.33 18.74

1.3 1.3


No Self assessed.

Kazdin &Siegel ‘92

PSI – PSST PMTCombined Beck depression PSST PMT Combined FES

252.6 t1 263.8 264

8.2 6.3 7.0

248.6 t2 263.7 219.4

6.2 7.8 4

4.0 0.1

44.6

2.0 1.5 3.0

0.08 0.001 0.99

0.26 0.23 0.46

Positive NS NS

P<0.001

P<0.05 P<0.001 P<0.001

No Self assessed.

Fuscaldo &Kaye ‘98

Coopersmith selfesteem PSI AAPI

Meanchange

6.6 -13.26 9.81

-0.75 -11,82 6.63

7.35 1.44 3.18

- - -

Positive

NS NS

P<0.001

No Self assessed.



Study Outcomemeasure

Measure att1 or control

Measure att2 orintervention



Y/N Mullin &Proudfoot ‘90

GHQ

5.96 t1 2.59 t2 3.37 - Positive P<0.001 No Self assessed.

Baum &Forehand ‘81

Parental attitudescore Home Behavioural Adjective

t1

13.97 29.71 29.68

t2

8.85 20.91 22.82

5.12 8.8

6.86

-

Positive

P<0.01 P<0.01 P<0.01

No Self assessed.



Appendix XI

Characteristics of studies looking at social and health service outcomes

Study Outcome Design Qualitycode

Population Intervention Comments.

Fuscaldo &Kaye 1998

Delayedpregnancy/ Furthereducation

PPS 4 31 Teenage mothers. Follow-up 2 years.

Teen parenting programme with:- Infant toddler centre- Parenting classes- Parent support group- Life skills training- Jobs skills training

Multisystems programme withmany components.Cannot record separate effect ofparent education component.

Trembley& Massi1995

DelinquencyCourt records

RCT 4 319 Disruptivekindergarden children.Follow-up – 10-15 years tomid adolescence.

Social skills and parent education. Home based parent training withschool based social skillstraining.

O’Donnel& Hawkins1995

Delinquencyand drug use

RCT 3 177 Low income urbanchildren.Follow-up – 6 years.

Seattle social development project.School based:-Classroom intervention-Child intervention-Parent intervention

Multisystems project.

Bank &Marlowe1991

Policecontacts

RCT 2 60 Chronically offendingdelinquents under 16years.Follow-up – 2 years.

Parent training Families multi-distressed.

Britner &Reppucci1997

Delayedpregnancy/FurthereducationAbuse

RCT 2 535 Newborns to at risksingle teenage mothers.Follow-up – 3-5years.

PET group work and support The groups were not similar atthe start of the study. The at riskgroup was actively recruited intothe experimental group and theyhad more risk factors.



Appendix XII

Outcome measures used for societal and health service outcomes.

Outcome area Measure used Assessment of measureDelayed pregnancy Telephone enquiry Open to bias.Further education Telephone enquiry Open to bias.Delinquency Court records

Police contactsTeacher ratingSelf reports

Not all crimes come to theattention of the police or courts.Open to bias.Open to bias.

Health service use Hospital records Independent measure.Child abuse rates Social services records Independent record but may not

reflect real situation.Drug use Self reports Open to bias.



Appendix XIII

Results of studies assessing societal and health service changes.

Outcome area Study Outcome measure Measure att1 or

control

Measure at t2or intervention


Significance test Independentrecord

Police contact Bank &Marlowe1991

Offense ratePolice contacts

Tl4.3911

T21.79

72.64

0.570.1

Positive NSNSNS

Police records

Tremblay &Massi1995

Court records Control9.3%

Intervention7.4% 1.9% - Negative NS

Police recordOnly 1-10%

offences come toattention of police.

Delinquency O’Donnel &Hawkins1995

DelinquencyGirlsBoys

Control0.570.67

Intervention0.560.41

0.010.26

0.020.5

Positive NSP<0.01

Self recorded

Tremblay &Massi 1995

Delinquency - - - - Positive NS Self recorded

Drug use O’Donneland Hawkins1995

Drug useGirlsBoys

Control0.170.06

Intervention0.040.06

0.130

0.340

Positive forgirls

P<0.05NS

Self reports

Delayedpregnancy

Britner &Repucci1997

Delayed Secondchild

Control57%

Intervention 71%

14% - Positive P<0.01 No

Fuscaldo &Kaye 1998

Control62%

Intervention89%

27% - Positive P<0.05 Yes



Outcome area Study Outcome measure Measure ti/ exp

Measure t2/control


Significance Independentmeasure y/n

Furthereducation

Fuscaldo &Kaye 1998

Completededucation

Control41%

Intervention84%

45% - Positive P<0.05 Yes

Britner &Repucci1997

Control50%

Intervention68%

18% - Positive NS Yes

Child abuse Britner &Repucci1997

Reported rates Control68%

Intervention50%

18% - Positive NS Social servicesrecords

Use of healthservices

Fuscaldo &Kaye 1998

Regular source ofhealth care

Control87%

Intervention100%

13% - Positive P>0.05 Self records



Appendix XIV

Cost analysis

1. Details of cost sources for cost analysis

The following outlines details of how the costs for the cost studies were derived.

• Staff costs for both the statutory and non statutory section are taken fromindependently assessed unit costs (39) and referred to in the table as ‘NHS costs’.It was assumed here that the statutory staff would be Health Visitors and the non-statutory staff appropriately qualified.Travel costs for statutory staff are included in the overall staff costings when theparent education is based in a centre and is set at £1 a visit for home visits. Thisrate is based on the same independently assessed unit costs. The wages of theHealth Visitors is taken as their opportunity cost. Working with vulnerablefamilies is now seen as core work for Health Visitors.

• Training costs from the ‘Handling Children’s Behaviour’ course run for HealthVisitors in Shropshire from local costings.

• Resource pack costs also from the ‘Handling Children’s Behaviour course’.

• Accommodation costs are taken from local costs in Shropshire. In model 1, where the programme is run in government buildings, the opportunity cost of accommodation was taken to be zero as such programmes are typically held in public buildings such as schools at times when the buildings would not otherwise be in use. The effect of including the opportunity cost of such accommodation on programme cost estimates can be seen by comparing model 1 and model 2, where the opportunity cost of accommodation is taken from local cost estimates of a local centre room. If the true opportunity cost of the use of public buildings is between zero and the cost of a local centre room, model 1 programme cost will lie between the estimates of model 1 and model 2.



1. Models of parent education training

Model 1: Statutory staff – government centre based

Cost centre Description Unit cost Estimate ofcost per course

Source

Staff Health visitor / equiv £38 per hour(clinic costs)

£760 NHS costings

Staff training Example – HandlingChildren’s behaviour

£82.60 £165 Local costings

Staff follow-up costs

Meetings to follow- upand organise courses

£16 per hour £80(5 meetings)

NHS costings

Resourcepacks

Included in training costsbut for copying

£1.25 perclient

£25 Local costings

Accommod-ation

Statutory building No cost No cost Na

Travel costs To and from centre only No extra cost Included instaff costs

NA

Creche costs Worker only in this case –3 workers for 2 hours

£44.70 persession

£447 Local costings

Here a breakdown is given of the initial costs to set up the course i.e. training andinitial support costs of staff and of the on-going costs i.e. those needed to provide theservice on an on-going basis

Total cost per course - Initial costs - £245- On-going costs - £1232

Total cost per client per course (based on 15 clients) - Initial £16.33 - On-going £82.13

Total cost per client per course (based on 8 clients) - Initial £30.62 - On-going £154



Model 2: Statutory staff – private centre based

Cost centre Description Unit cost Estimate ofcost percourse

Source

Staff Health visitor / equiv £38 per hour(clinic costs)

£760 NHS costings

Stafftraining

Example – HandlingChildren’s behaviour


Follow-up Meetings to follow- upand organise courses


NHS costings

Resourcepacks

Included in trainingcosts but for copying

£1.25 perclient

£25 Local costings

Accomm-odation

Local centre room £46.50 persession

£467.50 Local costings


NA

Creche Room and worker – 3workers for 2 hours

£59.45 persession







Model 3: Non-statutory (voluntary) staff – private centre based


Source

Staff Volunteer worker £12 per hour(clinic costs)

£240 NHS costings

Stafftraining



Follow-up Meetings to follow- upand organise courses


NHS costings

Resourcepacks

Included in trainingcosts but for copying

£1.25 perclient

£25 Local costings

Accomm-odation

Local centre room £46.50 persession



NA

Creche. Room and worker – 3workers for 2 hours

£59.45 persession







Model 4: Statutory staff - home visiting

Cost centre Description Unit cost Estimate ofcost per

individualcourse

Source

Staff Health visitor / equiv £55 per hour(home visitcosts)

£1100 NHS costings

Stafftraining



Follow-upcosts.

Meetings after course £12 £60 NHS costings

Resourcepacks


£1.25 £1.25 NHS costings

Accomm-odation

Not applicable

Travel costs Extra for visits £1 per visit £20 NHS costingsCreche Not applicable

Total cost per client per course - Initial costs - £2 - On-going costs - £1121 per client/



Model 5: Non-statutory staff - home visiting


Perindividual

Source

Staff Volunteer worker £12 per hour(clinic costs)

£240 NHS costings

Stafftraining



Follow-upcosts



NHS costings

Resourcepacks

Handling childrensbehaviour

£ 1.25 perclient


Accomm-odation

Not applicable

Travel costs For home visits £1 per visit £20 NHS costings

Total cost per client per course - Initial costs - £225 - On-going costs - £261 per client/


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